Approximately 6 in 10 eligible uninsured African Americans in the United States could obtain Health Insurance Marketplace tax credits, Medicaid, or the Children’s Health Insurance Program (CHIP). This ASPE Issue Brief discusses the demographics of the eligible uninsured African American population and new health insurance coverage options available to them under the Affordable Care Act. There are 6.8 million eligible uninsured African Americans nationwide, according to data from the 2011 American Community Survey Public Use Microdata Sample, and one-sixth of all eligible uninsured in the United States are African American. Under the Affordable Care Act, 2.2 million uninsured African Americans may be eligible for Marketplace tax credits and 2 million for Medicaid or CHIP coverage.

Under the Affordable Care Act, 6.8 million eligible
uninsured African Americans will have access to new options for health care
coverage starting January 1, 2014.[1]
Six in ten, or 4.2 million, of these eligible uninsured African Americans may
qualify either for tax credits to purchase coverage in the Health Insurance
Marketplace (2.2 million) or for Medicaid or the Children’s Health Insurance
Program (CHIP) (2.0 million). If all states were to expand Medicaid, 95 percent
of all eligible uninsured African Americans would be eligible for Marketplace
tax credits, Medicaid, or CHIP.

Of the 41.3 million uninsured nonelderly U.S. citizens and
others lawfully residing in the United States (a group referred to as “eligible
uninsured” in this brief), 6.8 million people or one in six (16 percent) are African
American. African Americans are uninsured at a higher rate than the U.S.
population overall; 16 percent of all nonelderly U.S. citizens and others
lawfully residing are uninsured, while the comparable proportion among eligible
African Americans is 20 percent.

Location — The five states with the greatest number
of eligible uninsured African Americans are:

The greater Atlanta, New York, Chicago, Dallas, Houston, and
Detroit metropolitan areas are home to one-fifth (21 percent) of eligible
uninsured African Americans (see Table 4). Approximately 15 percent of eligible
uninsured African Americans live outside a metropolitan area, a lower
proportion than among the eligible uninsured population overall (19 percent).

Gender —More men than women are
uninsured in the United States. This is also the case for African Americans. Among
eligible uninsured African Americans, less than half, or 44 percent (3.0
million) are women.

Age —Young adults are a
disproportionately large share of the uninsured relative to their share of the
general population. They are the age group most likely to be without health
insurance coverage in the U.S.[2]
The same is true among young African Americans: young adults ages 18 to 35
account for nearly half (3.2 million; 47 percent) of the African American
eligible uninsured but only 30 percent of the eligible African American
population overall. Of the 3.2 million eligible uninsured African Americans
ages 18 to 35, 1.3 million (41 percent) are women and 1.9 million (59 percent)
are men.

Employment — Most (73 percent) of eligible
uninsured Americans live in households with at least one full-time worker. Similarly,
six in ten (61 percent) eligible uninsured African Americans have at least one
full-time worker in the family.

Education —About one-fifth (19
percent) of eligible uninsured African Americans did not earn a high school
diploma, 71 percent have a high school diploma, and an additional 9 percent
hold a college degree. Among all eligible uninsured Americans nationwide (41.3
million), 20 percent do not have a high school diploma, 68 percent have a high
school diploma, and 12 percent hold a college degree.

Language —Nearly all (97 percent) of
eligible uninsured African Americans report that they speak English as a first
language or at least “very well” as a second language. Among those who do not,
the most common language is French Creole, which is spoken by 1 percent of
eligible uninsured African Americans.

Income —More than half (3.8 million;
55 percent) of all eligible uninsured African Americans have family incomes[3]
below 100 percent of the Federal Poverty Level (FPL), and nearly two-thirds of
these people (2.4 million) live in states that are not expanding Medicaid. This
means that more than one in three eligible uninsured African Americans may not
gain access to affordable coverage through Medicaid in 2014 because their state
declined to take the federally funded option to expand Medicaid eligibility.

Approximately 4.4 million eligible uninsured African
Americans have family incomes at or below 138 percent of the FPL, the threshold
for qualifying for Medicaid in expansion states. Of these 4.4 million, 1.5
million live in Medicaid expansion states.[4]

Table 1:
Distribution of Eligible Uninsured African Americans by Family Income

Each state has a Health Insurance Marketplace where
consumers can shop for and purchase health insurance coverage. In states that
are expanding Medicaid, individuals and families with household incomes from
138 to 400 percent of the FPL may be eligible for tax credits to make health
insurance even more affordable. In states that do not expand Medicaid, those
with family incomes between 100 and 400 percent of FPL may qualify for tax
credits.

Of the 2.6 million uninsured African Americans eligible to
purchase Marketplace plans, 2.2 million—or nearly 9 in 10 (86 percent)—may
qualify for a premium tax credit for Marketplace coverage (see Table 2).[7]The estimated 2.6 million
Marketplace-eligible uninsured include 762,000 eligible uninsured African
American adults (ages 19 and older) in Medicaid expansion states with incomes
above 138 percent of the FPL, 1.7 million eligible uninsured in the remaining
25 non-expansion states with incomes above 100 percent of the FPL, and 117,000
eligible uninsured African American children from all states with family
incomes above 250 percent of the FPL.[8]

Table 5 contains examples
of premiums before and after tax credits are applied.

African Americans and Medicaid

Many uninsured African Americans may be eligible for
coverage through Medicaid or the Children’s Health Insurance Program (CHIP) at
little or no cost. About 1.4 million eligible uninsured African American adults
(21 percent of all eligible uninsured African Americans) who reside in states
expanding their Medicaid programs may be eligible for Medicaid coverage.
Additionally, approximately 615,000 eligible uninsured African American children
ages 0 to 18 have family incomes at or below 250 percent of FPL and may be
eligible for coverage under Medicaid/CHIP (see Table 2).

More than 2.2 million African American adults live in states
that are not expanding Medicaid and have family incomes below 100 percent of
the FPL. If all states were to expand Medicaid, 95 percent of all eligible
uninsured African Americans would be eligible for Marketplace tax credits,
Medicaid, or CHIP.

Table 2: Number and Percentage of Eligible Uninsured
African Americans Who May Qualify for Marketplace Tax Credits, Medicaid, or
CHIP

Eligible uninsured African Americans who may qualify for
or Medicaid/CHIP (age 0 to 18)

175,000

440,000

615,000

2.6%

6.5%

9.0%

African Americans by Location

By State— As noted earlier, eligible
uninsured African Americans are generally concentrated in Southern states.
Nearly two-fifths (38 percent) live in Florida, Georgia, Louisiana, North
Carolina, and Texas. Table 3 shows the number of eligible African Americans and
those who are uninsured in all 50 states and the District of Columbia.

Table 3: Number of Eligible Uninsured African Americans
by State

State

Total Eligible African American Population

Eligible Uninsured African Americans

Percent of Eligible African Americans Who Are
Uninsured

Eligible Uninsured African Americans as Percent of
U.S. Total

Alabama

1,157,000

226,000

19.6%

3.3%

Alaska

20,000

3,000

14.9%

0.0%

Arizona

229,000

50,000

21.8%

0.7%

Arkansas

421,000

84,000

19.9%

1.2%

California

1,914,000

335,000

17.5%

4.9%

Colorado

176,000

32,000

18.3%

0.5%

Connecticut

303,000

32,000

10.5%

0.5%

Delaware

171,000

18,000

10.4%

0.3%

District of Columbia

260,000

26,000

10.1%

0.4%

Florida

2,563,000

677,000

26.4%

9.9%

Georgia

2,716,000

631,000

23.2%

9.2%

Hawaii

23,000

2,000

6.8%

0.0%

Idaho

7,000

1,000

14.2%

0.0%

Illinois

1,650,000

339,000

20.6%

5.0%

Indiana

529,000

122,000

23.1%

1.8%

Iowa

76,000

14,000

17.8%

0.2%

Kansas

145,000

28,000

19.4%

0.4%

Kentucky

318,000

77,000

24.3%

1.1%

Louisiana

1,336,000

340,000

25.4%

5.0%

Maine

15,000

1,000

6.5%

0.0%

Maryland

1,505,000

183,000

12.2%

2.7%

Massachusetts

356,000

25,000

7.0%

0.4%

Michigan

1,238,000

241,000

19.5%

3.5%

Minnesota

248,000

38,000

15.3%

0.6%

Mississippi

1,023,000

241,000

23.6%

3.5%

Missouri

612,000

130,000

21.3%

1.9%

Montana

3,000

2,000

53.1%

0.0%

Nebraska

72,000

15,000

21.3%

0.2%

Nevada

189,000

44,000

23.3%

0.6%

New Hampshire

11,000

2,000

21.9%

0.0%

New Jersey

981,000

161,000

16.4%

2.4%

New Mexico

31,000

4,000

12.3%

0.1%

New York

2,454,000

354,000

14.4%

5.2%

North Carolina

1,856,000

380,000

20.5%

5.6%

North Dakota

5,000

1,000

12.3%

0.0%

Ohio

1,239,000

233,000

18.8%

3.4%

Oklahoma

252,000

64,000

25.2%

0.9%

Oregon

61,000

12,000

19.5%

0.2%

Pennsylvania

1,172,000

201,000

17.2%

2.9%

Rhode Island

48,000

8,000

16.6%

0.1%

South Carolina

1,170,000

263,000

22.4%

3.9%

South Dakota

9,000

2,000

27.2%

0.0%

Tennessee

981,000

193,000

19.7%

2.8%

Texas

2,683,000

617,000

23.0%

9.0%

Utah

27,000

5,000

17.0%

0.1%

Vermont

4,000

1,000

12.8%

0.0%

Virginia

1,394,000

246,000

17.7%

3.6%

Washington

212,000

42,000

19.9%

0.6%

West Virginia

51,000

16,000

32.4%

0.2%

Wisconsin

326,000

58,000

17.7%

0.8%

Wyoming

5,000

1,000

19.9%

0.0%

United States

34,248,000

6,820,000

19.9%

100.0%

By Metropolitan Area— Eligible
uninsured African Americans are concentrated in certain metropolitan areas as
shown in Table 4, which lists the top 20 metropolitan statistical areas by the
number of eligible uninsured African Americans. Four in ten of the nation’s
eligible uninsured African Americans live in one of these 20 metropolitan
areas.

This table includes premiums for two illustrative groups, a
single 27-year-old and a family of four, in major metropolitan areas in
selected states with large eligible uninsured African American populations. For
example, in Jefferson County, Alabama, which includes the city of Birmingham, a
27-year-old with income of $25,000 could purchase a bronze plan for as little
as $104 per month after the tax credit. If a city spans more than one county,
the premiums below are for the county which covers a larger area of the city.

This analysis is based on ASPE analysis of the 2011 American
Community Survey Public Use Microdata Sample (ACS PUMS), the best source for
obtaining information about the current characteristics of the uninsured
population at the state level and for smaller demographic groups. ASPE tabulations
from the ACS PUMS have been adjusted to exclude estimated undocumented persons
based on ASPE’s TRIM3 microsimulation model (http://trim.urban.org).[16]

The smallest geographic unit defined in the ACS PUMS is the
Census-defined public-use microdata area (PUMA). To obtain metropolitan area
estimates, we assigned PUMAs to metropolitan statistical areas based on a
crosswalk created from the University of Minnesota’s Integrated Public Use
Microdata Series.[17]

Our methodology for examples of plan premiums is described
in detail in an earlier ASPE brief titled “Health Insurance Marketplace
Premiums for 2014.” The full text is available online at

For family incomes used to estimate Marketplace and Medicaid
eligibility, the “family” is defined as the “health insurance unit” (HIU). HIUs
include adults plus their spouses and dependent children (ages 0 to 18, plus
full-time students under age 23) living in the household, based on ASPE
analysis of the ACS PUMS data.

The estimate of uninsured Medicaid-eligible adults is the
number of adults age 19 older who have family (HIU) incomes below 138 percent
of the FPL and live in one of the 25 Medicaid expansion states or the District
of Columbia. Although the statutory threshold for Medicaid expansion set by the
Affordable Care Act is 133 percent of the FPL, this brief uses 138 percent of
the FPL, which is the effective threshold when the 5 percent statutory
disregard is included.

We made the simplifying
assumption that children in families with incomes at or below 250 percent of
FPL are eligible for CHIP, and children in families with incomes between 250
percent and 400 percent of the FPL are eligible for Marketplace coverage with
premium tax credits. We recognize that states have different maximum income
standards for CHIP eligibility.

[1]
ASPE tabulations from the CY 2011 American Community Survey Public Use
Microdata Sample (ACS PUMS) are adjusted to exclude estimated undocumented
persons based on ASPE’s TRIM3 microsimulation model. All references to eligible
uninsured in this brief use these tabulations. See the methodology section for
more information. For more information about eligibility to purchase coverage
in the Marketplace, see https://www.healthcare.gov/immigration-status-and-the-marketplace/.
The estimates contained in this brief do not take into account certain
Marketplace coverage and Medicaid/CHIP eligibility requirements, such as those
relating to other minimum essential coverage or tax filing requirements, and
thus the populations described in this brief should be construed as “potentially”
eligible, subject to these other requirements. Also, the statutory threshold
for Medicaid expansion set by the Affordable Care Act is 133 percent of the
FPL, not 138 percent of the FPL. This brief refers throughout to 138 percent of
the FPL, which is the effective threshold including the 5 percent statutory
disregard.

[3]
For family income, a “family” is based on the “health insurance unit” (HIU),
which includes adults, their spouses, and their dependent children (ages 0-18,
plus full-time students under age 23), using ASPE analysis of the ACS PUMS
data.

[5]
The sum of expansion and non-expansion state estimates may not equal the stated
total for all states due to rounding.

[6]
Estimates in this row are for all nonelderly (ages 0 to 64) African American
who are U.S. citizens or lawfully residing in the United States.

[7]
We define Marketplace-tax-credit-eligible individuals in this analysis as
uninsured U.S. citizens and others lawfully residing in the area served by the
Marketplace who are adults (ages 19 to 64) with family incomes above 138
percent to 400 percent of the FPL in Medicaid expansion states and above 100
percent to 400 percent of the FPL in non-expansion states or who are children
(ages 0 to18) with incomes 250 percent to 400 percent of the FPL.

[8]
We make the simplifying assumption in this analysis that all children with
incomes below 250 percent of the FPL would be eligible for Medicaid/CHIP rather
than the Marketplace.

[9]
The sum of expansion and non-expansion state estimates may not equal the stated
total for all states due to rounding.

[10]
In non-expansion states, some eligible uninsured may currently qualify for
Medicaid and are not enrolled, and such individuals are not included in our
analysis. For expansion states, our estimate of the eligible uninsured who may
qualify for Medicaid includes both the current and the newly eligible.

[11]
The 15-state total is based on the 15 states corresponding to the top 20 MSAs
listed in the table, not the 15 states by greatest number of eligible uninsured
African Americans.

[12]
For the purposes of this analysis, a family of four is defined as two 30-year-old
adults and two children.

[13]
Net of tax credits, bronze premiums for a family of four may be below those for
a single individual and may be as low as 0. This occurs because the tax credit
is calculated as the difference between the cost of the second lowest cost
silver plan premium and the maximum payment amount determined by income.
Because premiums for older individuals and families are higher than those for
younger individuals, tax credits are larger for older individuals and families.
Therefore, using tax credits to purchase a bronze plan may yield lower bronze
premiums for older individuals.

[14]
Los Angeles County is split into two rating areas for Marketplace premiums.

[15]
Information on the lowest-price catastrophic plan in the Baltimore metro area
was not readily available.

[16]
The adjustment methodology is based on imputations of immigrant legal status in
ASPE’s TRIM3 microsimulation model (http://trim.urban.org/), according to
methods initially developed by Jeffrey Passel and Rebecca Clark.

[17]
The Integrated Public Use Microdata Series (Version 5.0) was developed by Steven
Ruggles, J. Trent Alexander, Katie Genadek, Ronald Goeken, Matthew B.
Schroeder, and Matthew Sobek at the University of Minnesota. Available online: https://usa.ipums.org/usa/index.shtml.